COURSE EVALUATION FOR ADMINISTRATIVE DIRECTOR As a part of the Administrative Director's ongoing efforts to ensure that courses for Qualified Medical Evaluators offer valuable information on California's Workers' Compensation-related medical evaluation issues, we are asking attendees of the courses approved by the Administrative Director (including distance learning programs) to complete the following Course Evaluation. Date of Course: Course Name: Course Provider: Maximum Course Hours Available: Content/Hand-out material Adequate/Accurate new information Educational Objective Met Pertinence to QME evaluations Knowledge of presenters Syllabus Legibility Adequacy of Room Adequacy of Audio Visual Overall Rating What improvement(s) would you suggest? Excellent 5 5 5 5 5 5 5 5 5 Hours Completed: Good 4 4 4 4 4 4 4 4 4 Satisfactory 3 3 3 3 3 3 3 3 3 Fair 2 2 2 2 2 2 2 2 2 Poor 1 1 1 1 1 1 1 1 1 TO ALL ATTENDEES: PLEASE RETURN THIS FORM TO THE DWC All education providers are required to provide this response form to all attendees and to advise all attendees that the form should be promptly returned to the Administrative Director at the address on the back of this form. QME Form 117 (rev. 2013) Apply proper postage DIVISION OF WORKERS' COMPENSATION - MEDICAL UNIT PO BOX 71010 OAKLAND, CA 94612 American LegalNet, Inc. www.FormsWorkFlow.com